Provider Demographics
NPI:1184606311
Name:LEAVELL, KEITH JAMES (MD)
Entity type:Individual
Prefix:
First Name:KEITH
Middle Name:JAMES
Last Name:LEAVELL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 6TH AVE N
Mailing Address - Street 2:CENTRACARE CLINIC
Mailing Address - City:SAINT CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56303-2735
Mailing Address - Country:US
Mailing Address - Phone:320-252-5131
Mailing Address - Fax:320-240-2118
Practice Address - Street 1:1200 6TH AVE N
Practice Address - Street 2:CENTRACARE CLINIC
Practice Address - City:SAINT CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56303-2735
Practice Address - Country:US
Practice Address - Phone:320-252-5131
Practice Address - Fax:320-240-2118
Is Sole Proprietor?:No
Enumeration Date:2005-11-15
Last Update Date:2013-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN34628207RP1001X, 207RS0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
1011246OtherPREFERRED ONE
597042OtherARAZ GROUP
112115OtherU CARE
COMPOtherMMSI
110122640OtherRR MEDICARE
597042OtherAMERICAS PPO
928880500OtherMEDICAL ASSISTANCE MA
COMPOtherONE HEALTH PLAN
COMPOtherGREAT WEST
HP10860OtherHEALTH PARTNERS
COMPOtherCHAMPUS
4800134OtherMEDICA HEALTH PLANS
C11369OtherRR MEDICARE
27T22LEOtherBLUE CROSS BLUE SHIELD
2114069OtherFIRST HEALTH PLAN
COMPOtherCHAMPUS
597042OtherARAZ GROUP